The International Journal of Tuberculosis and Lung Disease Guidelines for preparing manuscripts on qualitative research in the IJTLD Ellen M. H. Mitchell, Ian Harper & Sally Theobald, Associate Editors, IJTLD Introduction There is debate about how to ensure quality in qualitative research, which is shaped by different theoretical positions. While there is no agreed checklist for qualitative research quality, there are quality standards that are maintained by the major biomedical journals and to which IJTLD adheres. 1 These guidelines are intended to improve the quality of qualitative manuscript submissions to the Journal. Scope Qualitative manuscripts are sought that shed light on why particular TB control and lung care efforts are successful or unsuccessful and how they can be improved. Research that focuses on experiences of diverse actors and their implications are welcome. Qualitative research that helps to overcome challenges of health care delivery (for example, TB prevention, access to services, diagnosis and adherence) are preferable to those that simply analyse problems and dilemmas. Rationale and specific aims Although qualitative studies may ask broad, exploratory and inter connected questions that are not always pre specifiable as conventional hypotheses, it is necessary to offer a cogent and well reasoned justification or rationale for your inquiry. 2 These might be construed as broad research issues to be investigated, rather than pre determined hypotheses. Background and significance Rather than a mere summary of what has been written before, the introduction should display a broad understanding of how the literature fits together and leads to the current inquiry. 3 Introductions should include relevant qualitative and quantitative literature on your topic. It is sometimes appropriate to adopt a critical stance towards what exists and highlight any gaps or methodological limitations of previous research, and at other times to stress the importance of previous work in informing your own study design. 3 Setting and context Qualitative findings are generally expected to be more context driven, relational and reflexive than quantitative findings. 4 A concise description of the setting(s) where the research took
2 place is essential. A common weakness in qualitative manuscripts submitted to the IJTLD has been a tendency to offer only a national or regional overview of notified cases and estimated prevalence, while neglecting the social, cultural, gender, economic or political context in which TB control is embedded. Good qualitative articles will illuminate the social, gender, cultural, economic, or political dynamics that shape transmission, case finding, diagnosis and treatment outcomes. 3 Theoretical frameworks Transparency about the conceptual framework(s) and theoretical perspectives applied is important. 1 The point of departure of most IJTLD manuscripts is cosmopolitan biomedicine. In qualitative research, the assumptions of cosmopolitan biomedicine may be treated as one of several aetiological frames that may be operating in a particular setting. 4 Methodology There should be a logical relationship between the research questions, the methods selected and the analytical approach chosen. It is important to avoid jargon. A lack of understanding of qualitative concepts among IJTLD audiences obliges authors be particularly explicit with the rationale behind their methodological choices. Many concepts (e.g., sampling, reliability, coding and observation) have different meanings in quantitative and qualitative research, so you need to be specific. There should be consistency in the ways in which key concepts are defined, used and subsequently applied throughout the manuscript. Table 1 offers some examples of how particular methodologies offer advantages for certain research aims. Table 1 Illustrative examples of qualitative methods suitable for specific topics Method Good for the study of Not ideal for the study of Interviews Experiences, perceptions, beliefs, attitudes, Clinical practices private discourses Focus groups Group dynamics, public discourses, community norms, Stigmatised behaviours, sensitive issues Ethnography Sub cultures, organisational cultures and Time sensitive issues practices, inter cultural interactions, habits, non adherence, enacted stigma, Structured Clinical practices, quality of care, infection Attitudes, perceptions observation control, etc. Textual analysis Policies, messaging, framing and representation Policy implementation Well written manuscripts will convince the reader that the methodology(ies) employed was/were the most appropriate by, crucially, linking it to the research question, and being transparent about the logic behind adaptations.
3 As with quantitative manuscripts, it is critical to address issues of access, consent, language, translation, recruitment, refusal, reimbursement and retention. In particular, if translation is undertaken, it may be necessary to describe this process, and explore the possible multiple meanings of words and phrases. In trying to interpret the experiences and meanings attributed to particular groups and cultures it is important that manuscripts do not reinforce stereotypes or use judgmental language. Always describe what quality controls were used to assess the validity or trustworthiness of the findings (e.g., piloting, triangulation, participant checking, etc.). 5,6 Sampling Avoid generalities. It is not sufficient to simply say that purposive sampling was used without defining the purpose behind it. Reviewers will want to know why certain characteristics were deemed important enough to guide selection and see these characteristics used in the analysis. Sample size There are multiple approaches to sample size determination in qualitative methods, and you can make reference to considerations including redundancy, saturation, stratification and range. A scientific (or at least credible) rationale for the sample size is required. 1 In ethnography and participant observation, samples might be quite small (n < 20), but the richness of the data set should compensate for the narrowness. It is a fallacy that sampling and sample size are unimportant in qualitative research. 7 Data collection Simply naming the data collection technique is insufficient (e.g., semi structured interviews). Data collection might be done using recording devices or in extensive field notes. This should be detailed appropriately. 1 Authors should indicate how potential threats to validity, such as social desirability bias or the Hawthorne effect, were addressed and discuss implications for the analysis. It is important to highlight steps the research team has undertaken to enhance the trustworthiness or rigour of the research approach, for example, participant checking, prolonged engagement or triangulation. 8 10 This should include disclosure of the linguistic, cultural, methodological competencies of the research team members. 1,3 Data analysis Simply saying a qualitative approach to analysis was undertaken is not sufficient. Specify if codes or themes were developed a priori or ad hoc (during the processing of data). 3 Unlike quantitative methods, in qualitative research, data collection and analysis are often concurrent. It is not essential to imply that they were linear or sequential if they were not. 11 Be clear and accountable about who participated in the analysis and what approach to analysis was undertaken, with links to the literature as appropriate. If multiple analysts coded the data, indicate whether and how inter coder reliability was assured. If qualitative software was used, fully describe the ways it was employed and any issues that may have restricted its utility. 12
4 Data interpretation Interpretation of data will depend on the questions asked, and on the theoretical and methodological approaches taken. 13 Historically, the audience of the IJTLD can be described as sceptical of and somewhat unfamiliar with qualitative methods, and it is therefore important to offer compelling proof that analytical methods are rigorous and transparent, yielding both fascinating and useful results. In qualitative research, there is a logical emphasis on the nature and quality of rapport between the research team and the participants. It is common practice to address the social position of the researcher (through taking a reflexive approach) in the manuscript and to scrutinise how this may influence the data gathered. 1,10 In quantitative work there is a tendency to strenuously defend one s method due to the inability to make mid course corrections. However, a good qualitative study may, and some argue should, evolve over time and generate unexpected findings. It is often difficult to determine in advance who holds the answer to the question and how best to get it. Therefore it is vital to describe what was done and any refinements of the research question or method in the course of the project. 11 This methodological flexibility is often mistaken for an acceptance of data collection that is driven by convenience or whimsy as opposed to a logical flow from theoretical imperatives. 3 The manuscript should offer a cogent rationale for why methods or instruments evolved. Quotations and thick description The use of quotes should be judicious and used to emphasise the main thrust of the analytical argument and interpretation being developed. 14 While the identities of participants are normally concealed, it is expected that some relevant descriptors are provided to enhance the interpretation of quotations. The voices of the participants and those of the researchers should be readily distinguishable. 10,12 Qualitative findings can also be well summarised in diagrammatic, tabular and numerical form if the pitfalls are avoided. 15 Limitations It is not essential that qualitative study results be representative or broadly generalisable, but it is essential to critically discuss the usefulness of findings that are not. 3,10 In some cases the theoretical implications of the study might be important. Consider the effect of relationships, cultural, class or gender disparities, limited access and other factors that impact the quality of the data collected. Share your manuscript with critical colleagues to anticipate reviewers concerns and discuss them. 3
5 Implications Authors are invited to place special emphasis on the utility of their findings and to emphasise how they should inform tuberculosis and lung health policy and practice. A note on length Because much social science research may involve quoting from participants, reflection on process, detailed description of context, and is less readily summarised in tabular form, it may require a higher word count than quantitative articles. 2,3 Therefore, the word count for a qualitative manuscript may be as high as 3,500 words. For ethnographies and case studies with extensive quotation or discourse analysis, we recommend that authors consider submission to our sister journal, Public Health Action, which accepts qualitative submissions of up to 8,000 words. Protecting human participants Qualitative manuscripts should be explicit about steps taken to shield participants from social and physical risks. When research involves hidden, stigmatised or marginalised populations, it is important to be clear and concise as to the procedures used to protect both privacy and confidentiality, prevent coercion, and uphold ethical principles of justice and beneficence. Similarly it is important to relate the responsibilities of the researchers to the relevant ethical guidelines (for example, those of the respective anthropological and sociological associations). The safety issues are frequently significantly different to those of quantitative research and should not be entirely over determined by medical ethics in isolation. 13 The justification for what was done, and how this was guided by certain ethical principles, may require reflection in the final article (rather than just a statement saying that relevant clearance has been achieved). Any queries can be directed to the Union s Ethics Advisory Group. Special topics: Literature reviews Literature reviews are welcome, particularly scoping reviews of qualitative research on particular issues of relevance to the Journal readership. These can be complex, however, and should address questions of comparability. 16 18 Pre submission queries are required for all review articles submitted to the IJTLD (see Instructions to Authors). Combining quantitative and qualitative methods Authors of mixed method manuscripts must make a very concise, yet compelling, case for how both methods mutually inform the study. 19 Mixed methods papers often require lengthy descriptions of study procedures, offering little space for discussion and conclusions. A common weakness is mixed method manuscripts is that one methodology is described comprehensively and the other is superficially developed. If both methods are used, it is essential to describe the relationship between the data collected. 20
6 Recommended resources for methodological guidance qualitative research 1. The Robert Wood Johnson Foundation has sponsored the Qualitative Research Guidelines Project t. This website is useful for people developing, evaluating and engaging in qualitative research projects in healthcare settings. https://c28lmydqm3bt4o2die.sec.amc.nl/ 2. For reporting of interview and focus groups data, the COREQ checklist is recommended: Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32 item checklist for interviews and focus groups. Int J Qual Health Care 2007; 19: 349 357. 3. British Medical Journal Qualitative Research Checklist http://resources.bmj.com/bmj/authors/checklists forms/editors checklists 4. Qualitative Methods in Health Research: Opportunities and Considerations in Application and Review. Office of Behavioral and Social Sciences Research National Institutes of Health.
7 References 1. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32 item checklist for interviews and focus groups. Int J Qual Health Care 2007; 19: 349 357. 2. Kitto S C, Chesters J, Grobich C. Quality in qualitative research. Med J Austr 2008; 188: 243 246. 3. Lamont M. Workshop on interdisciplinary standards for systematic qualitative research. Washington, DC, USA: National Science Foundation, 2009 http://www.nsf.gov/sbe/ses/soc/issqr_workshop_rpt.pdf Accessed November 2011. 4. Horsburgh D. Evaluation of qualitative research. J Clin Nurs 2003; 12: 307 312. 5. Collingridge D S, Gantt E E. The quality of qualitative research. Am J Med Qual 2008; 23: 389 395. 6. Mays N, Pope C. Qualitative research in health care: assessing quality in qualitative research. Brit Med J 7226; 320: 50 52. 7. Sandelowski M. Sample size in qualitative research. Res Nurs Health 1995; 18: 179 183. 8. Sandelowski M. Rigor or rigor mortis: the problem of rigor in qualitative research revisited. ANS. Adv Nurs Sci 1993; 16: 1 8. 9. Tuckett A G. Part II. Rigour in qualitative research: complexities and solutions. Nurse Res 2005; 13: 29 42. 10. Malterud K. Qualitative research: standards, challenges, and guidelines. The Lancet 2001; 358: 483 488. 11. Forman J, Creswell J W, Damschroder L, Kowalski C P, Krein S L. Qualitative research methods: key features and insights gained from use in infection prevention research. Am J Infect Control 2008; 36: 764 771. 12. Sandelowski M. On the aesthetics of qualitative research. Image J Nursing Schol 1995; 27: 205 209. 13. Stige B, Malterud K, Midtgarden T. Toward an agenda for evaluation of qualitative research. Qual Health Res 2009; 19: 1504 1516. 14. Sandelowski M. The use of quotes in qualitative research. Res Nurs Health 1994; 17: 479 482. 15. Sandelowski M. Real qualitative researchers do not count: the use of numbers in qualitative research. Res Nurs Health 2001; 24: 230 240. 16. Sandelowski M, Voils C I, Barroso J, Lee E J. 'Distorted into clarity': a methodological case study illustrating the paradox of systematic review. Res Nurs Health 2008; 31: 454 465. 17. Sandelowski M. Docherty S, Emden C. Focus on qualitative methods. Qualitative metasynthesis: issues and techniques. Res Nurs Health 1997; 20: 365 371. 18. Sandelowski M. Reading, writing and systematic review. J Adv Nurs 2008; 64: 104 110. 19. Morse J M. Serving two masters: the qualitatively driven, mixed method proposal. Qual Health Res 2008; 18: 1607 1608. 20. Sandelowski M. Combining qualitative and quantitative sampling, data collection, and analysis techniques in mixed method studies. Res Nurs Health 2000; 23: 246 255.